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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1700334

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Case Details

VAERS ID: 1700334 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-12
Onset:2021-09-12
   Days after vaccination:184
Submitted: 0000-00-00
Entered: 2021-09-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cough, Oxygen saturation decreased, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HTN, Atherosclerosis of bilat legs, meningioma of brain
Allergies: Lisinopril (swelling), Choline and Magnesium salicylate (swelling of face)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt acquired covid-19 several months after administration of vaccine that requires hospitalization. Symptoms include sever, cough, decreased O2 saturation requiring supplemental oxygen administration.


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